Online Registration

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ONLINE REGISTRATION

	Payment Information

	Why Sign Up

	Sign up Now

» Online Registration Form

APPLICATION FORM

Please fill all fields marked with " * ".

PERSONAL DETAILS

Full Name as in NRIC *

:

NRIC *

:

Citizenship *

:

Date of Birth *

:

-	-
MM	DD	YYYY

Gender *

:

Male

Female

Race *

:

	Malay		Chinesse		Indian
	Others

Indicate the festival(s) you celebrate? *

Chinese New Year

Hari Raya

Deepavali

Christmas

CONTACT DETAILS

Correspondence Address *

:

Postcode *

:

State *

:

Country *

House Telephone Number *

:

(if dont have,just put "-")

Office Telephone Number

:

Handphone Number *

:

Telco Provider		Number
		-

Email Address

:

(alternative e-mail address)

Occupation *

:

OTHERS INFORMATION

Do You Have Your Own Computer? *

Yes

No

Do You Currently Hold a Credit Card? *

:

	Yes		No
	VISA		Mastercard

Do You Have Any Life Insurance Policy(s)? *

Yes

No

Current Policy(s)

Do you own a vehicle? *

Yes

No

Road Tax Expiry Date

Car Model

How did you hear about ACTIVE? *

	Website (ubusiness2me.com)
	Event Registration
	Promotion Email
	Friend / Family
	Area / State Coordinator
	Agent
	Others

Are you a member of a Sport Association? *

Yes

No

How many day in a year you go for holiday? *

Where is your location for holiday? *

Domestic

International

Do you choose Active as your service launcher? *

Yes

No

PAYMENT DETAILS

Please select your preferred method of payment? *

Please select your package?

Get Active Membership Card for MYR 99.00 / USD 26.00

Active Membership Package Features:
1 Membership for 1 Year 1 Round-neck t-shirt 1 Cap Free Delivery (Domestic & International) Check to buy this product